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Dede BT, Oğuz M, Bağcıer F, Aytekin E. Bibliometric analysis of the 100 most cited articles on cubital tunnel syndrome. J Orthop 2025; 64:34-38. [PMID: 39654638 PMCID: PMC11625345 DOI: 10.1016/j.jor.2024.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2024] [Accepted: 11/17/2024] [Indexed: 12/12/2024] Open
Abstract
Background The aim of this study was to analyze the 100 most cited articles (T100) on Cubital Tunnel Syndrome (CuTS). Methods T100 articles were identified using the Web of Science database with the keyword cubital tunnel syndrome on January 10, 2024. Bibliometric analysis included information such as article title, total number of citations, number of authors, author names, country of publication, year of publication, type of publication, subject covered, journal publishing, h-index of publishing journals, Q classification, and impact factor. Results The number of citations for T100 articles ranged between 28 and 183. Journal of Hand Surgery - American Volume (n = 28) was the journal with the highest number of T100 articles. In the comparison between countries, the United States of America (n = 55) was represented by the highest number of articles. The evaluation of the main topics covered in the articles showed that surgical treatment (n = 64) was the main topic in the majority of T100 articles. Conclusion The results of this study provide insight into the scientific community's interest in CuTS. This study can be a guide for further research and potential solutions for CuTS.
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Affiliation(s)
- Burak Tayyip Dede
- Department of Physical Medicine and Rehabilitation, Cemil Tascioglu City Hospital, Istanbul, Turkey
| | - Muhammed Oğuz
- Department of Physical Medicine and Rehabilitation, Istanbul Training and Research Hospital, Istanbul, Turkey
| | - Fatih Bağcıer
- Department of Physical Medicine and Rehabilitation, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Ebru Aytekin
- Department of Physical Medicine and Rehabilitation, Istanbul Training and Research Hospital, Istanbul, Turkey
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Spies CK, Cavalcanti Kußmaul A, Heinz M, Bruckner T, Müller LP, Unglaub F, Ayache A. Long term functional outcome for the cubital tunnel syndrome after endoscopic assisted release of the ulnar nerve. Arch Orthop Trauma Surg 2024; 145:72. [PMID: 39708061 DOI: 10.1007/s00402-024-05694-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 09/30/2024] [Indexed: 12/23/2024]
Abstract
INTRODUCTION The endoscopic assisted release for cubital tunnel syndrome (CuTS) gained popularity in recent years with unclear long-term results. This study aims to evaluate long term results regarding functional and subjective outcomes after endoscopic assisted release for the CuTS. MATERIALS AND METHODS Thirty one patients who have been treated by endoscopic assisted release for CuTS between 2006 and 2013 were followed up both clinically and with a questionnaire with a mean follow up of 152 months (range 120-204 months). Functional and subjective parameters were evaluated and statistically compared to the contralateral elbow. For statistical evaluation one-sample t-test and the McNemar test were defined as appropriate. RESULTS Pinch grip strength, two-point discrimination, application of Semmes-Weinstein monofilaments, Tinel's sign, grip and three-point pinch strength showed no significant difference. The DASH score was 14,2 with 96,6% of patients rating good/excellent results. CONCLUSIONS This study found the endoscopic assisted release of the ulnar nerve to be an efficacious and safe method for the treatment of CuTS.
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Affiliation(s)
- C K Spies
- Department of Orthopaedics, Traumatology, and Hand Surgery, Spital Langenthal, St. Urbanstraße 67, 4900, Langenthal, Switzerland.
- Department of Orthopaedics, Traumatology, and Reconstructive Surgery, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany.
| | | | - M Heinz
- Hand Surgery, Vulpius Klinik, Vulpiusstraße 29, 74906, Bad Rappenau, Germany
- Medical Faculty Mannheim, Heidelberg University, 68167, Mannheim, Germany
| | - T Bruckner
- The Department of Medical Biometry and Informatics, University Heidelberg, Im Neuenheimer Feld 305, 69120, Heidelberg, Germany
| | - L P Müller
- Department of Orthopaedics, Traumatology, and Reconstructive Surgery, University Hospital Cologne, Kerpener Str. 62, 50937, Cologne, Germany
| | - F Unglaub
- Hand Surgery, Vulpius Klinik, Vulpiusstraße 29, 74906, Bad Rappenau, Germany
- Department of Orthopaedics and Trauma Surgery, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, 68167, Mannheim, Germany
| | - A Ayache
- Hand Surgery, Vulpius Klinik, Vulpiusstraße 29, 74906, Bad Rappenau, Germany
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Chan FY, Lam C, Butorac R, Willemot L. Snapping Triceps Syndrome: Surgical Technique. Tech Hand Up Extrem Surg 2024; 28:129-131. [PMID: 38439654 DOI: 10.1097/bth.0000000000000475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Abstract
Snapping triceps syndrome is a rare cause of medial elbow pain and ulnar neuritis caused by subluxation and triggering of the medial tricipital muscle belly over the medial distal humeral ridge and condyle. The diagnosis and surgical management of snapping triceps syndrome can be challenging due to the subtlety of the symptoms and the infrequent presentation. Despite the diagnosis relying largely on clinical examination, noninvasive dynamic ultrasonography may facilitate detection. Correct recognition of this condition is crucial in the avoidance of surgical misadventure and revision surgery. This paper illustrates our surgical technique for the management of snapping triceps and reviews the available literature on this relatively obscure condition.
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Affiliation(s)
| | - Caroline Lam
- Department of Plastic and Reconstructive Surgery, Launceston General Hospital, Australia
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Kamineni S, Pooley J, Bachoura A, Yoshida R, Cummings J. Triceps brachii insertional footprint: Under-estimated complexity. Shoulder Elbow 2024; 16:321-329. [PMID: 38818100 PMCID: PMC11135194 DOI: 10.1177/17585732221135633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 10/02/2022] [Accepted: 10/05/2022] [Indexed: 06/01/2024]
Abstract
Background The detailed complexity of triceps brachii insertional footprint continues to challenge surgeons as evidenced by continued reports of triceps-associated complications following elbow procedures. The purpose of this study is to describe the three-dimensional footprint of the triceps brachii at its olecranon insertion at the elbow. Methods 22 cadaveric elbows were dissected leaving only the distal insertion of the triceps intact. The insertion was defined and probed with a three-dimensional digitizer to create a digital three-dimensional footprint allowing width, height, and surface area of the footprint to be recorded relative to the bare area. The insertional soft tissues of tendon versus muscle along with the shape of the footprints were qualitatively described. Results The mean width and surface area of the lateral segment was greater in males than in females (30.07 mm vs. 24.37 mm, p = 0.0339 and 282.1 mm vs. 211. 56 mm, p = 0.0181, respectively). No other statistically significant differences between the sexes were noted. The triceps insertional footprint was "crescent-shaped" and consisted of three regions: central tendon, medial muscular extension, and lateral muscular extension. Discussion These findings can help explain the importance of avoiding these muscular structures during triceps-off approaches and provides the framework for future clinical studies. Clinical Relevance: Basic Science, anatomy study, cadaver dissection.
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Affiliation(s)
- Srinath Kamineni
- Department of Orthopaedic Surgery and Sports Medicine, Elbow Shoulder Research Center, University of Kentucky, Lexington, KY, USA
| | - Joseph Pooley
- Orthopaedic Department, Queen Elizabeth Hospital, Gateshead, UK
| | | | - Ruriko Yoshida
- Department of Operations Research, Naval Postgraduate School, Monterey, CA, USA
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Cho CH, Lim KH, Kim DH. Bilateral snapping triceps syndrome: A case report. World J Clin Cases 2023; 11:8228-8234. [PMID: 38130777 PMCID: PMC10731183 DOI: 10.12998/wjcc.v11.i34.8228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 11/24/2023] [Accepted: 11/28/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Snapping triceps syndrome (STS) is a rare disease, while occurrence of bilateral STS is extremely rare. It is usually accompanied by dislocation of the ulnar nerve and double snapping is a clinically important feature. However, to the best of our knowledge, there has been no report of bilateral STS in young active patient. CASE SUMMARY A 23-year-old male presented with a complaint of discomfort and snapping on the medial side of both elbows while performing push-ups. On physical examination, two distinct snaps that were both palpable and audible were detected on additional clinical examination. Dynamic ultrasonography showed that the ulnar nerve and the medial head of the triceps were dislocated anteriorly over the medial epicondyle of the elbow during flexion motion. Finally, he was diagnosed as dislocation of the ulnar nerve and STS. Staged anterior subcutaneous transposition of the ulnar nerve combined with partial resection of the snapping portion of the triceps was performed. The patient's pain and snapping symptoms were resolved immediately after surgery. Three months later, the patient was completely asymptomatic and returned to normal activity. CONCLUSION STS should be included in the differential diagnosis for active young patients who present with painful snapping on the medial side of the elbow joint, particularly when dislocation of the ulnar nerve is detected. Dynamic sonography is used to assist in accurate diagnosis and differentiation between isolated dislocation of the ulnar nerve and STS.
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Affiliation(s)
- Chul-Hyun Cho
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu 42601, South Korea
| | - Kyung-Hwan Lim
- Orthopedic Surgery, Allright Hospital, Daegu 42038, South Korea
| | - Du-Han Kim
- Department of Orthopedic Surgery, Keimyung University Dongsan Hospital, Keimyung University School of Medicine, Daegu 42601, South Korea
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Schoch C, Geyer M. [Surgical treatment of snapping triceps syndrome]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2019; 32:171-178. [PMID: 31690973 DOI: 10.1007/s00064-019-00635-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 04/07/2019] [Accepted: 04/22/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Treatment of a persistently painful snapping triceps and possibly snapping ulnar nerve. INDICATION Snapping triceps. CONTRAINDICATIONS General surgical risks. SURGICAL TECHNIQUE Following the anterior transposition of the ulnar nerve (subcutaneously or submuscular), the snapping portion of the triceps tendon is transsected and reinforced, and transposition of the medial triceps margin into the central triceps portion is carried out. POSTOPERATIVE MANAGEMENT Cast for 5-7 days; for a total of 6 weeks functional exercise without maximum flexion and resistance exercise of the triceps. Weight loading after 3 months. RESULTS In the case presented, complaints were absent after 3 months. Full load exercise, e.g., push-ups, was achieved 4 months after surgery. There was no recurrent snapping within the first year. The results of this case are in agreement with the 25 patients previously reported in the PubMed literature. Recurrence, gross restrictions of movement, and complications were not observed in patients who underwent surgery.
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Affiliation(s)
- C Schoch
- St. Vinzenz Klinik Pfronten, Kirchenweg 15, 87459, Pfronten im Allgäu, Deutschland.
| | - M Geyer
- St. Vinzenz Klinik Pfronten, Kirchenweg 15, 87459, Pfronten im Allgäu, Deutschland
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Feller RJ, Gil JA, DaSilva M. Snapping at the Lateral Aspect of the Elbow: A Case Report and Review of the Literature. JBJS Case Connect 2018; 8:e48. [PMID: 29995662 DOI: 10.2106/jbjs.cc.17.00198] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
CASE A 59-year-old man presented with snapping at the lateral aspect of the elbow and associated pain. Magnetic resonance imaging demonstrated extensor tendinopathy and thickening of the radial collateral ligament. Ultrasonography showed entrapment of a synovial fold in the radiohumeral joint. Initial arthroscopic debridement did not alleviate the snapping. Three months later, the patient underwent open excision of a thickened and partially torn annular ligament; subsequently, all of the symptoms resolved. CONCLUSION Snapping elbow is a phenomenon that often coincides with pain and limited function. Accurate diagnosis is critical because misdiagnosis has been demonstrated to have serious consequences, including the need for repeat surgery.
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Affiliation(s)
- Ross J Feller
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Joseph A Gil
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
| | - Manuel DaSilva
- Department of Orthopaedic Surgery, Warren Alpert School of Medicine, Brown University, Providence, Rhode Island
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Bjerre JJ, Johannsen FE, Rathcke M, Krogsgaard MR. Snapping elbow-A guide to diagnosis and treatment. World J Orthop 2018; 9:65-71. [PMID: 29686971 PMCID: PMC5908985 DOI: 10.5312/wjo.v9.i4.65] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Revised: 02/07/2018] [Accepted: 03/02/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To develop practical guidelines for diagnosis and treatment of the painful snapping elbow syndrome (SE).
METHODS Clinical studies were searched in the databases PubMed and Scopus for the phrases “SE”, “snapping triceps”, “snapping ulnar nerve” and “snapping annular ligament”. A total of 36 relevant studies were identified. From these we extracted information about number of patients, diagnostic methods, patho-anatomical findings, treatments and outcomes. Practical guidelines for diagnosis and treatment of SE were developed based on analysis of the data. We present two illustrative patient cases-one with intra-articular pathology and one with extra-articular pathology.
RESULTS Snapping is audible, palpable and often visible. It has a lateral (intra-articular) or medial (extra-articular) pathology. Snapping over the medial humeral epicondyle is caused by dislocation of the ulnar nerve or a part of the triceps tendon, and is demonstrated by dynamic ultrasonography. Treatment is by open surgery. Lateral snapping over the radial head has an intra-articular pathology: A synovial plica, a torn annular ligament or a meniscus-like remnant from the foetal elbow. Pathology can be visualized by conventional arthrography, magnetic resonance (MR) arthrography, high resolution magnetic resonance imaging (MRI) and arthroscopy, while conventional MRI and radiographs often turn out normal. Treatment is by arthroscopic or eventual open resection. Early surgical intervention is recommended as the snapping can damage the ulnar nerve (medial) or the intra-articular cartilage (lateral). If medial snapping only occurs during repeated or loaded extension/flexion of the elbow (in sports or work) it may be treated by reduction of these activities. Differential diagnoses are loose bodies (which can be visualized by radiographs) and postero-lateral instability (demonstrates by clinical examination). An algorithm for diagnosis and treatment is suggested.
CONCLUSION The primary step is establishment of laterality. From this follows relevant diagnostic measures and treatment as defined in this guideline.
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Affiliation(s)
- Jonathan Jetsmark Bjerre
- Section for Sportstraumatology M51, Bispebjerg-Frederiksberg Hospital, Copenhagen NV DK-2400, Denmark
| | - Finn Elkjær Johannsen
- Institute for Sportsmedicine M81, Bispebjerg-Frederiksberg Hospital, Copenhagen NV DK-2400, Denmark
| | - Martin Rathcke
- Section for Sportstraumatology M51, Bispebjerg-Frederiksberg Hospital, Copenhagen NV DK-2400, Denmark
| | - Michael Rindom Krogsgaard
- Section for Sportstraumatology M51, Bispebjerg-Frederiksberg Hospital, Copenhagen NV DK-2400, Denmark
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Shimizu H, Beppu M, Arai T, Kihara H, Izumiyama K. Ultrasonographic findings in cubital tunnel syndrome caused by a cubitus varus deformity. HAND SURGERY : AN INTERNATIONAL JOURNAL DEVOTED TO HAND AND UPPER LIMB SURGERY AND RELATED RESEARCH : JOURNAL OF THE ASIA-PACIFIC FEDERATION OF SOCIETIES FOR SURGERY OF THE HAND 2012; 16:233-8. [PMID: 22072453 DOI: 10.1142/s0218810411005473] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 03/22/2011] [Accepted: 03/22/2011] [Indexed: 12/23/2022]
Abstract
We have retrospectively reviewed the clinical, preoperative ultrasonographic, and operative findings of eight patients who had tardy ulnar nerve palsy caused by a cubitus varus deformity. The mean varus angle on the affected side was 23°. With preoperative ultrasonography, the anterior dislocation of the ulnar nerve from the medial epicondyle was detected in dynamic scanning of short-axis images, and long-axis images revealed nerve compression and kinking in the proximal border of the flexor carpi ulnaris. Operative findings revealed compression of the ulnar nerve by a fibrous band, which was released in all cases. The cause of the tardy ulnar nerve palsy in this series of patients was constriction by a fibrous band and kinking in the proximal border of the flexor carpi ulnaris due to ulnar nerve dislocation from compression resulting from the forward movement of the medial head of the triceps brachii muscle.
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Affiliation(s)
- H Shimizu
- Department of Orthopaedic Surgery, St. Marianna University School of Medicine, Kawasaki 211-8511, Japan.
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Abstract
Acute and chronic elbow pain is common, particularly in athletes. Although plain radiographs, ultrasound, and computed tomography all have a role to play in the investigation of elbow pain, magnetic resonance imaging (MRI) has emerged as the imaging modality of choice for diagnosis of soft tissue disease and osteochondral injury around the elbow. The high spatial resolution, excellent soft-tissue contrast, and multiplanar imaging capabilities of MRI make it ideal for evaluating the complex joint anatomy of the elbow. This article reviews imaging of common disease conditions occurring around the elbow in athletes, with an emphasis on MRI.
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Affiliation(s)
- Kathryn J Stevens
- Department of Radiology, Stanford University Medical Center, Stanford University School of Medicine, Room S-062A Grant Building, 300 Pasteur Drive, Stanford, CA 94305-5105, USA.
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Richard MJ, Messmer C, Wray WH, Garrigues GE, Goldner RD, Ruch DS. Management of subluxating ulnar nerve at the elbow. Orthopedics 2010; 33:672. [PMID: 20839711 DOI: 10.3928/01477447-20100722-04] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Musculotendinous variations around the medial epicondyle can contribute to subluxation of the ulnar nerve at the elbow. This article reviews the presenting symptoms, operative findings, and results of surgery for subluxation of the ulnar nerve at the elbow. A retrospective evaluation was performed of 200 elbows managed operatively for medial elbow pathology over a 17-year period between 1990 and 2007. The patient charts were reviewed for chief complaint, radiographic studies, operative reports, and postoperative examination data. Seventeen patients (18 elbows) were treated for a subluxating ulnar nerve. Three patients were women and 14 were men, with a mean age of 27.6 years. Medial elbow pain was the chief complaint in all 17 patients. Seventeen elbows also demonstrated paresthesias in an ulnar nerve distribution. All patients were treated with anterior transposition of the ulnar nerve, and 11 patients (61%) were found to have a muscular anomaly. At a mean follow-up of 17 months, the mean visual analog scale for pain improved from 6.0 to 2.0. There was no functional impairment reported for any patient at final follow-up. Of the 200 elbows surgically treated for medial elbow pathology, 17 patients (8.5%) demonstrated a subluxating ulnar nerve. These patients tend to be young and present with a primary complaint of medial elbow pain. In addition, a subluxating ulnar nerve is often associated with muscular anomalies, which must be addressed concurrently.
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Affiliation(s)
- Marc J Richard
- Department of Orthopedic Surgery, Duke University Medical Center, Durham, North Carolina, USA
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Spinner RJ, Goldner RD. Snapping of the medial head of the triceps: diagnosis and treatment. Tech Hand Up Extrem Surg 2009; 6:91-7. [PMID: 16520623 DOI: 10.1097/00130911-200206000-00008] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Robert J Spinner
- Assistant Professor Departments of Neurologic Surgery and Orthopedics Mayo Medical School Rochester, MN, U.S.A.
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15
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Watts AC, McEachan J, Reid J, Rymaszewski L. The snapping elbow: a diagnostic pitfall. J Shoulder Elbow Surg 2008; 18:e9-10. [PMID: 18667338 DOI: 10.1016/j.jse.2008.03.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2007] [Revised: 02/20/2008] [Accepted: 03/24/2008] [Indexed: 02/01/2023]
Affiliation(s)
- Adam C Watts
- Queen Margaret Hospital, Dunfermline, Fife, United Kingdom.
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Abstract
Surgical procedures for the treatment of ulnar nerve compression at the elbow are well described. Studies have reported clinical outcomes after decompression of the nerve without transposition and decompression with transposition. Numerous preoperative, intraoperative, and postoperative factors contribute to failure of the surgical procedures. Although the techniques available for revision decompression of the ulnar nerve at the elbow are similar to those used in the primary setting, the results after repeat surgical intervention are less predictable.
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Affiliation(s)
- David E Ruchelsman
- Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, 301 East 17th Street, 14th Floor, New York, NY 10003, USA
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Boon AJ, Spinner RJ, Bernhardt KA, Ross SR, Kaufman KR. Muscle activation patterns in snapping triceps syndrome. Arch Phys Med Rehabil 2007; 88:239-42. [PMID: 17270523 DOI: 10.1016/j.apmr.2006.11.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To compare the muscle activation pattern in subjects with and without "snapping triceps syndrome" (dislocation of the medial head of the triceps and ulnar nerve over the medial epicondyle). DESIGN Controlled study. SETTING Biomechanics laboratory. PARTICIPANTS Eight male subjects (9 elbows), with symptomatic snapping triceps and 9 male controls. INTERVENTIONS Not applicable. MAIN OUTCOME MEASURES Activation pattern of the 3 triceps heads during active elbow extension at 0 degrees , 45 degrees , 70 degrees , 90 degrees , and 115 degrees of flexion, recorded by fine-wire electromyography. RESULTS There were no significant differences between subjects and controls in the firing pattern of the triceps heads. The medial head fired first in 6 of 9 symptomatic elbows and in 7 of 9 controls at 90 degrees of flexion, and in 6 of 9 elbows of both subjects and controls at 115 degrees of flexion, positions where snapping typically occurs. There was no significant difference between the groups as to how often the medial head fired maximally. CONCLUSIONS This study suggests the firing pattern of the triceps heads may not contribute to the pathogenesis of this syndrome. Rather, the authors believe the anatomic position of the medial head causes it to dislocate over the medial epicondyle, often resulting in ulnar neuritis.
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Affiliation(s)
- Andrea J Boon
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Rochester, MN 55905, USA
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Jeon IH, Oh CW, Kyung HS, Park IH, Kim PT. Tardy ulnar nerve palsy in cubitus varus deformity associated with ulnar nerve dislocation in adults. J Shoulder Elbow Surg 2006; 15:474-8. [PMID: 16831653 DOI: 10.1016/j.jse.2005.10.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2005] [Accepted: 10/18/2005] [Indexed: 02/01/2023]
Abstract
Seven patients with tardy ulnar nerve palsy from a posttraumatic cubitus varus deformity were reviewed retrospectively. The severity of symptoms was grade I in 3 patients and grade II in 4 patients according to McGowan's classification. The mean internal rotation angle was 30.7 degrees (range, 25 degrees -45 degrees ). The most prominent feature was dislocation of the nerve anterior to the medial epicondyle and entrapment of the nerve by the fibrous band of the flexor carpi ulnaris muscle. Of these 7 patients, 4 were treated by 3-dimensional osteotomy with ulnar nerve transposition, and 3 were treated by anterior transposition of the ulnar nerve. All patients improved clinically, and there was no significant difference between anterior transposition of the nerve in the group with osteotomy and the group without osteotomy. Ulnar nerve instability due to internal rotation deformity and distal entrapment was considered to be the main cause of neuropathy.
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Affiliation(s)
- In-Ho Jeon
- Department of Orthopaedic Surgery, Kyungpook National University Hospital, Daegu, Korea
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Abstract
Variations of the triceps brachii muscle are apparently rare. We report an additional attachment site of the medial head of the triceps brachii found on the left side of a male cadaver. This head originated from the posterior aspect of the surgical neck of the humerus. Clinicians diagnosing or treating patients with weakness or pain of the posterior arm should consider anomalous muscles in this region that may result in neurovascular compression.
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Affiliation(s)
- R Shane Tubbs
- Section of Pediatric Neurosurgery, University of Alabama at Birmingham and Children's Hospital Birmingham, Alabama 35233, USA.
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Kijowski R, Tuite M, Sanford M. Magnetic resonance imaging of the elbow. Part II: Abnormalities of the ligaments, tendons, and nerves. Skeletal Radiol 2005; 34:1-18. [PMID: 15480640 DOI: 10.1007/s00256-004-0854-y] [Citation(s) in RCA: 127] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2004] [Revised: 07/30/2004] [Accepted: 08/03/2004] [Indexed: 02/02/2023]
Abstract
Part II of this comprehensive review on magnetic resonance imaging of the elbow discusses the role of magnetic resonance imaging in evaluating patients with abnormalities of the ligaments, tendons, and nerves of the elbow. Magnetic resonance imaging can yield high-quality multiplanar images which are useful in evaluating the soft tissue structures of the elbow. Magnetic resonance imaging can detect tears of the ulnar collateral ligament and lateral collateral ligament of the elbow with high sensitivity and specificity. Magnetic resonance imaging can determine the extent of tendon pathology in patients with medial epicondylitis and lateral epicondylitis. Magnetic resonance imaging can detect tears of the biceps tendon and triceps tendon and can distinguishing between partial and complete tendon rupture. Magnetic resonance imaging is also helpful in evaluating patients with nerve disorders at the elbow.
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Affiliation(s)
- Richard Kijowski
- Department of Radiology, University of Wisconsin Hospital, Madison, Wisconsin, USA.
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Abstract
The elbow is a trochoginglymus joint with three articulations (the ulnohumeral, radiocapitellar, and proximal radioulnar joints) and two degrees of freedom (flexion/extension and pronation/supination). The congruity of the articulations as well as the medial and lateral collateral ligament complexes account for a majority of the stability of the joint. Muscles play a dynamic role in stabilizing the elbow. Understanding the anatomy and biomechanics of the elbow is essential to diagnosing and treating problems that develop in a patient's elbow.
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Affiliation(s)
- Jess G Alcid
- Ocean Orthopedic Associates, PA, 20 Hospital Drive, Suite 12, Toms River, NJ 08755, USA
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Spinner RJ, An KN, Kim KJ, Goldner RD, O'Driscoll SW. Medial or lateral dislocation (snapping) of a portion of the distal triceps: a biomechanical, anatomic explanation. J Shoulder Elbow Surg 2001; 10:561-7. [PMID: 11743537 DOI: 10.1067/mse.2001.118006] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Medial and lateral snapping (dislocation) of the distal triceps over the epicondyle during elbow flexion has been reported but is frequently misdiagnosed and is not well understood. In this study a mathematical model was designed to simulate the effect that bony abnormalities at the distal humerus and soft tissue variations of the distal triceps have on the line of pull of the triceps. The predictions were then tested on prefabricated and fabricated plastic elbow models, as well as 8 cadaveric elbows. When the bony alignment was altered, varus angulation had the greatest effect: 30 degrees varus malalignment of the distal humerus displaced the centroid of the triceps vector medially by approximately 2.0 cm. Valgus malalignment had a lesser effect: 30 degrees valgus displaced it laterally by 1.5 cm. Negligible effects on the triceps line of pull were seen with internal or external malrotation and with flexion or extension malalignment. Of the soft tissue alterations, displacement of the triceps insertion had a greater effect than movement of the triceps origin. The triceps vector was displaced by approximately 70% of the amount of translation of the triceps insertion. The relationship between the triceps line of pull and the bony alignment is represented by the triceps (T) angle. Our use of the T angle to understand snapping triceps is analogous to the use of the quadriceps (Q) angle for patellar subluxation/dislocation. Treatment should aim to restore normal triceps biomechanics with soft tissue or bony procedures.
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Affiliation(s)
- R J Spinner
- Department of Neurologic Surgery, Mayo Clinic Foundation, Rochester, Minn 55905, USA.
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24
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O'Driscoll SW, Spinner RJ, McKee MD, Kibler WB, Hastings H, Morrey BF, Kato H, Takayama S, Imatani J, Toh S, Graham HK. Tardy posterolateral rotatory instability of the elbow due to cubitus varus. J Bone Joint Surg Am 2001; 83:1358-69. [PMID: 11568199 DOI: 10.2106/00004623-200109000-00011] [Citation(s) in RCA: 154] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Cubitus varus has long been considered merely a cosmetic deformity. The purpose of this paper is to demonstrate a causal relationship between cubitus varus and instability of the elbow. METHODS In twenty-four patients (twenty-five limbs) with a cubitus varus deformity following a pediatric distal humeral fracture or resulting from a congenital anomaly (three limbs of two patients), tardy posterolateral rotatory instability of the elbow developed approximately two to three decades after the deformity occurred. All patients presented with lateral elbow pain and recurrent instability. The average varus deformity was 15 degrees (range, 0 degrees to 35 degrees ). Surgery was performed in twenty-one patients (twenty-two limbs). Treatment consisted of reconstruction of the lateral collateral ligament and osteotomy in seven limbs, ligament reconstruction alone in ten, osteotomy alone in four, and total elbow arthroplasty in one. RESULTS In three patients, the triceps muscle was dynamically stimulated intraoperatively to contract while resisting extension of the elbow. This produced posterolateral rotatory subluxation of the elbow, which was reversed by corrective osteotomy and lateral transposition of a portion of the medial head of the triceps that originally had been attached to the elongated, deformed medial aspect of the olecranon. At an average of three years (minimum, one year) after the operation, the result was good or excellent for nineteen of the twenty-two limbs that had undergone an operation; three limbs had persistent instability. CONCLUSIONS With cubitus varus, the mechanical axis, the olecranon, and the triceps line of pull are all displaced medially. The repetitive external rotation torque on the ulna permitted by these deformities can stretch the lateral collateral ligament complex and lead to posterolateral rotatory instability. Thus, cubitus varus deformity secondary to supracondylar malunion or congenital deformity of the distal part of the humerus may not always be a benign condition and may have important long-term clinical implications. Operative correction can relieve symptoms of instability. The indications for preventive corrective osteotomy remain to be determined.
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25
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Re.: Correction of cubitus varus by French or dome osteotomy. THE JOURNAL OF TRAUMA 2001; 50:1159-60. [PMID: 11426137 DOI: 10.1097/00005373-200106000-00032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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26
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Melikyan EY, Burke FD. Dislocating medial head of triceps--awareness of the condition could avoid inappropriate surgery--a case report. ACTA ORTHOPAEDICA SCANDINAVICA 2000; 71:324-6. [PMID: 10919309 DOI: 10.1080/000164700317411979] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- E Y Melikyan
- Pulvertaft Hand Centre, Derbyshire Royal Infirmary, UK.
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27
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Fukuhara S, Kanazawa Y, Uchida S, Akahoshi S, Yoshioka T, Nakamura T. Increased levels of chondrocalcin in knee joint fluid in synovial chondromatosis--a case report. ACTA ORTHOPAEDICA SCANDINAVICA 2000; 71:326-7. [PMID: 10919310 DOI: 10.1080/000164700317411988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- S Fukuhara
- Department of Orthopaedic Surgery, University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
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28
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Spinner RJ, O'Driscoll SW, Jupiter JB, Goldner RD. Unrecognized dislocation of the medial portion of the triceps: another cause of failed ulnar nerve transposition. J Neurosurg 2000; 92:52-7. [PMID: 10616082 DOI: 10.3171/jns.2000.92.1.0052] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECT Failed surgical treatment for ulnar neuropathy or neuritis due to dislocation of the ulnar nerve presents diagnostic and therapeutic challenges. The authors of this paper will establish unrecognized dislocation (snapping) of the medial portion of the triceps as a preventable cause of failed ulnar nerve transposition. METHODS Fifteen patients had persistent, painful snapping at the medial elbow after ulnar nerve transposition, which had been performed for documented ulnar nerve dislocation with or without ulnar neuropathy. The snapping was caused by a previously unrecognized dislocation of the medial portion of triceps over the medial epicondyle. Seven of the 15 patients also had persistent ulnar nerve symptoms. The correct diagnosis of snapping triceps was delayed for an average of 22 months after the initial ulnar nerve transposition. An additional surgical procedure was performed in nine of the 15 cases and, in part, consisted of lateral transposition or excision of the offending snapping medial portion of the triceps. Of the four patients in this group who had persistent neurological symptoms, submuscular transposition was performed in the two with more severe symptoms and treatment of the triceps alone was performed in the two with milder neurological symptoms. Excellent results were achieved in all surgically treated patients. Six patients declined additional surgery and experienced persistent snapping and/or ulnar nerve symptoms. CONCLUSIONS Failure to recognize that dislocation of both the medial portion of the triceps and the ulnar nerve can exist concurrently may result in persistent snapping, elbow pain, and even ulnar nerve symptoms after a technically successful ulnar nerve transposition.
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Affiliation(s)
- R J Spinner
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota 55905, USA.
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29
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Minami A, Kato H, Iwasaki N. Snapping of Triceps Tendon After Anterior Nerve Transposition for Recurrent Subluxation of the Ulnar Nerve. HAND SURGERY : AN INTERNATIONAL JOURNAL DEVOTED TO HAND AND UPPER LIMB SURGERY AND RELATED RESEARCH : JOURNAL OF THE ASIA-PACIFIC FEDERATION OF SOCIETIES FOR SURGERY OF THE HAND 1999; 4:193-196. [PMID: 11089180 DOI: 10.1142/s0218810499000253] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- A Minami
- Department of Orthopaedic Surgery, Hokkaido University, School of Medicine, Sapporo, Japan
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30
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Spinner RJ, O'Driscoll SW, Davids JR, Goldner RD. Cubitus varus associated with dislocation of both the medial portion of the triceps and the ulnar nerve. J Hand Surg Am 1999; 24:718-26. [PMID: 10447163 DOI: 10.1053/jhsu.1999.0718] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Five patients with cubitus varus deformities from malunited childhood fractures had dislocation (snapping) of both the medial portion of the triceps and the ulnar nerve over the medial epicondyle. In addition to snapping, these patients had medial elbow pain or ulnar nerve symptoms. Cubitus varus shifts the line of pull of the triceps more medial, which can cause anteromedial displacement of the medial portion of the triceps during elbow flexion. The ulnar nerve is concomitantly pushed or pulled anteromedially by the triceps, and ulnar neuropathy may result from friction neuritis or from dynamic compression by the triceps against the epicondyle. Recognition of both the dislocating ulnar nerve and the snapping medial triceps is crucial in the successful treatment of this pathologic finding. In symptomatic individuals, we recommend either corrective valgus osteotomy of the distal humerus or partial excision or lateral transposition of the snapping medial triceps, or a combination of both. Alternatively, medial epicondylectomy can also eliminate the snapping. Transposition of the ulnar nerve can be performed for ulnar nerve symptoms and/or ulnar nerve instability. Using this approach, correction of the snapping and/or ulnar nerve symptoms was achieved in all cases.
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Affiliation(s)
- R J Spinner
- Department of Neurologic Surgery, Mayo Clinic/Mayo Foundation, Rochester, MN, USA
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31
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Abstract
We present a patient with translocation (snapping) of a portion of the triceps over the lateral epicondyle with elbow flexion. This condition is in many ways analogous to its counterpart at the medial aspect of the elbow, snapping of the medial head of the triceps, a clinical entity that is being increasingly recognized.
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Affiliation(s)
- R J Spinner
- Department of Neurologic Surgery, Mayo Clinic/Mayo Foundation, Rochester, MN, USA
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32
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Sakai K, Kanamori M, Kitano S. Extension restriction of the elbow caused by a synovial fold--a report on 2 athletes. ACTA ORTHOPAEDICA SCANDINAVICA 1999; 70:85-6. [PMID: 10191756 DOI: 10.3109/17453679909000965] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- K Sakai
- Department of Orthopedic Surgery, Kamioka Town Hospital, Gifu pref., Japan
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33
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34
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Spinner RJ, Davids JR, Goldner RD. Dislocating medial triceps and ulnar neuropathy in three generations of one family. J Hand Surg Am 1997; 22:132-7. [PMID: 9018626 DOI: 10.1016/s0363-5023(05)80193-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Variations in the medial triceps in conjunction with bilateral ulnar neuropathy have been identified in three generations of one family also possessing the phenotype of Waardenburg syndrome (a rare autosomal-dominant disorder with clinical features including cochlear deafness, dystopia canthorum, and pigmentation problems). To our knowledge, no other inherited condition with triceps anomalies has been reported. Study of this family provided insight into the relationship between dislocating medial triceps and ulnar neuropathy and demonstrated that a broad spectrum of clinical presentations exists-from being completely asymptomatic to producing symptomatic snapping and ulnar neuropathy.
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Affiliation(s)
- R J Spinner
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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35
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Affiliation(s)
- R W Coonrad
- Division of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA
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36
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Mitsunari A, Muneshige H, Ikuta Y, Murakami T. Internal rotation deformity and tardy ulnar nerve palsy after supracondylar humeral fracture. J Shoulder Elbow Surg 1995; 4:23-9. [PMID: 7874561 DOI: 10.1016/s1058-2746(10)80004-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Internal rotation deformity may contribute to the onset of tardy ulnar nerve palsy after a supracondylar fracture. We measured the angle of deformity in five patients with nerve palsy using an electrogoniometer and compared it with that of patients without palsy. Varus deformity of patients with nerve palsy was 23 degrees +/- 15.2 degrees (mean +/- SD), and that of patients without palsy was 12 degrees +/- 10.9 degrees. No significant difference was seen between the two groups. Internal rotation deformity of patients with nerve palsy was 16 degrees +/- 4.2 degrees, and that of patients without palsy was 2.5 degrees +/- 6.3 degrees (p < 0.05). The results suggest that internal rotation deformity contributes to the development of tardy ulnar nerve palsy.
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Affiliation(s)
- A Mitsunari
- Department of Orthopedic Surgery, Akitsu Prefectural Hospital, Hiroshima-ken, Japan
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37
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Abstract
Fifteen patients with tardy ulnar nerve palsy caused by cubitus varus deformity were studied. All patients had a history of previous fracture of the humerus during childhood. The mean interval between fracture and onset of symptoms was 15 years. The severity of the palsy was classified as McGowan's grade I in 12 patients, grade II in 2 patients, and grade III in 1 patient. The mean carrying angle was -2 degrees before surgery. X-ray films showed a shallow ulnar nerve groove, a dysplastic humeral trochlea, medial shift of the ulna, and deformity of the medial epicondyle. The ulnar nerve was explored in all but one patient. Operative findings suggested that the main cause of the palsy was compression by a fibrous band running between the two heads of flexor carpi ulnaris. Surgical steps included release of the fibrous band in 14 patients with anterior subcutaneous transposition of the ulnar nerve in 5 of those patients. A corrective osteotomy was done in 11 patients who requested correction of the varus deformity. Traumatic cubitus varus deformity should be recognized as another cause of cubital tunnel syndrome.
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Affiliation(s)
- M Abe
- Department of Orthopaedic Surgery, Osaka Medical College, Japan
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38
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Matsuura S, Kojima T, Kinoshita Y. Cubital tunnel syndrome caused by abnormal insertion of triceps brachii muscle. JOURNAL OF HAND SURGERY (EDINBURGH, SCOTLAND) 1994; 19:38-9. [PMID: 8169476 DOI: 10.1016/0266-7681(94)90046-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Some cases of cubital tunnel syndrome are caused by anatomical abnormalities such as the epitrochleo-anconeus muscle or snapping and bulkiness of the medial head of the triceps brachii muscle. We report a rare cause of cubital tunnel syndrome that has not been reported previously. It was caused by an abnormal insertion of the medial head of the triceps muscle into the medial epicondyle. The clinical course and operative findings are described.
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Affiliation(s)
- S Matsuura
- Department of Plastic and Reconstructive Surgery, Jikei University School of Medicine, Tokyo, Japan
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39
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40
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Uchida Y, Sugioka Y. Ulnar nerve palsy after supracondylar humerus fracture. ACTA ORTHOPAEDICA SCANDINAVICA 1990; 61:118-9. [PMID: 2360426 DOI: 10.3109/17453679009006501] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Six patients with cubitus varus deformity after a supracondylar fracture of the humerus had ulnar nerve palsy 7 (3-14) years following the fracture. All the patients showed anterior dislocation of the ulnar nerve during elbow flexion. In cubitus varus deformity, medial shifting of the triceps muscle occurs, which pushes the ulnar nerve anteriorly and frequently causes ulnar-nerve dislocation. Five of the 6 patients underwent surgery with subsequent improvement.
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Affiliation(s)
- Y Uchida
- Department of Orthopedics, Faculty of Medicine, Kyushu University, Fukuoka, Japan
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Abstract
Retrospective analysis of 48 medial epicondylectomy procedures in 46 patients demonstrated that symptomatic and objective improvement was usual. Most patients experienced improvement of symptoms (98%) and moving two-point discrimination (87%), and many demonstrated improved motor strength (54%). By use of the McGowan scheme for grading ulnar neuropathy, 92% of the patients with grade I neuropathy had a return to normal function. Subdividing patients with grade II neuropathy into grade IIA and IIB on the basis of the extent of motor compromise was useful in predicting postoperative outcome. Forty-five percent of the patients with grade IIA neuropathy had a return to normal ulnar nerve function and only 11% (one patient) in the IIB group had a full recovery. In the group with grade III neuropathy, one patient had improvement to grade II level and the other five remained grade III. No patient in this study demonstrated deterioration of his McGown grade. Medial epicondylectomy is a safe and predictable procedure for the treatment of symptomatic cubital tunnel syndrome.
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Affiliation(s)
- B J Goldberg
- Department of Orthopaedics and Rehabilitation, Loyola University Medical Center, Maywood, IL 60153
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42
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Abstract
There are five major anatomical locations where the ulnar nerve may be compressed near the elbow. Multiple sites of compression are often noted clinically; in other cases, the site of compression is difficult to identify. Clinical experience and results of a series of 20 anatomical dissections suggest that local decompression or subcutaneous transfer may be performed without necessarily exposing all five locations, posing a risk of incomplete decompression. Submuscular transfer of the ulnar nerve decompresses all five locations simultaneously and thus theoretically may be more reliable. The potentially superior results predicted by this anatomical investigation have been confirmed in a clinical case review. Submuscular transposition of the ulnar nerve is reliable and safe, not only in the primary treatment of ulnar neuropathy at the elbow but also in revision of previous operations.
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